Pediatric emergency medicine trisk 4582 4582
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of children ingesting CS powder are known, which resulted only in transient
diarrhea and abdominal cramping.
Miscellaneous Chemicals
The potential of a terrorist attack on industrial sources of dangerous chemicals
such as factories, railroad and vehicular tank cars, or storage depots expands the
list of potential “chemical weapons” considerably. In addition, the development
of potent incapacitating agents, such as fentanyl derivatives, by law enforcement
or military agencies for use in combating terrorist incidents, might unfortunately
lead to mass casualties requiring medical treatment, as illustrated by the October
2002 theater hostage incident in Moscow. A full discussion of all such possible
chemical injuries and their management is beyond the scope of this discussion. In
general, many of the relevant industrial chemicals (e.g., methyl isocyanate,
ammonia, nitrogen dioxide, sulfur oxides) might be expected to induce
respiratory effects analogous to those of chlorine or phosgene discussed
previously; others (e.g., strong acids or alkalies, hydrogen fluoride,
formaldehyde, and acrolein) could cause dermatologic injury from irritant or
caustic properties, as well as more systemic effects in severe exposures ( Table
132.5 ). Fentanyl derivatives can be lethal from suppression of the respiratory
center in the medulla of the brain. Further information is available from standard
reference toxicology textbooks and by consultation with the regional poison
control center (1-800-222-1222).
Emergency Department Preparedness
The ED response to chemical exposure incidents should be integrated with the
hospital’s All-Hazards Emergency Operations Plan. There must be protocols for
mass notification of key personnel, using hospital security for patient direction
and crowd control at the ED entrance and around the decontamination site, and
handling the dissemination of information to the public and news media. Hospital
spaces that are not routinely used for patient care, such as cafeterias, may be used
as holding areas for large numbers of exposed but minimally symptomatic
patients. Such patients may constitute up to 80% of those seeking medical
attention. An “upside-down” triage pattern may also be observed: Less critically
affected patients may arrive first at the hospital (and begin to overwhelm medical
resources), followed later by ambulances transporting the more severely exposed.
Routine hospital supplies such as gowns and towels may be depleted rapidly in
the face of mass casualties. Demands for critical care beds, ventilators, and other
resources may exceed availability. Alternative care facilities (e.g., schools,
gymnasiums, or warehouses) staffed by outside help may be needed in mass-
